Among veterans using VA care, physical and mental health status are comparable across genders in each age stratum, except that mental health status is better for elderly women than for elderly men. Health status is also comparable across genders after controlling for age, race/ethnicity, and education. The association between indicators of social support and health status is complex; being married or living with someone benefits mental health status in men but not in women (among patients less than 65 years old), whereas having instrumental support benefits mental health status in both men and women.
Overall, the health status of women veterans is comparable to the health status of male veterans, who represent the bulk of VA clinicians' practices, and who are well known to be much sicker, on average, than the general population.1–4
Our findings are generally similar to prior VA work by Skinner et al.15
except that in that study, women veterans had even lower mental health function than did a comparison group of men; however, unlike our national study, theirs was conducted at a single tertiary care VA facility which was a referral center for women with posttraumatic stress disorder. Therefore, our findings extend this line of inquiry by being nationally representative.
Comparing mean SF-36 subscale scores of the women veterans in our cohort (who had a mean age of 52 years) to those of women in the general population31
(who had a mean age of 46 years40
), women veterans have consistently and markedly worse scores in every domain of physical and mental health (see ). Likewise, comparing mean SF-36 subscale scores of the women veterans in our cohort to care-seeking private sector patients in the Medical Outcomes Study (who were 53% female and had a mean age of 55 years),32
scores in the general population of women veteran VA patients were comparable to or worse than scores of the subset of private sector patients who had “serious chronic medical conditions” (symptomatic congestive heart failure patients, myocardial infarction survivors with recurring angina and/or severe congestive heart failure symptoms, hypertension patients with severe congestive heart failure symptoms and/or history of stroke, and diabetes patients with severe complications). Differences were particularly marked for Bodily Pain (mean score 49.1 vs 65.1 in women veteran VA patients vs care-seeking private sector patients with serious medical conditions, respectively), Role Emotional (60.6 vs 76.2, respectively) and Social Function (59.8 vs 80.0, respectively).32
Thus, like male veteran patients, women veterans in VA have particularly poor health status.
FIGURE 1 Mean Short Form 36 subscale scores (unadjusted) in women veterans in the current study (gray bars) compared with Medical Outcomes Study data31 for women in the general population (black bars). PF, Physical Function; RP, Role Functioning, Physical; BP, (more ...)
The reasons for the ill health of women veterans in VA are unknown; indeed, the finding is somewhat surprising given that good health is a prerequisite to entering the military. It could be that exposures during military service (such as physical injuries, toxic exposures, combat exposure, or military sexual trauma) distinguish women veterans from non-veteran women, adversely affecting their health.8–10, 41–43
High-risk behaviors, such as smoking or substance use, could begin during military service and persist after discharge from the armed services.44, 45
The vast majority of the 1.6 million women veterans in the United States do not receive VA care. It could be that women who elect to use VA services are sicker than other women veterans, perhaps related in part to economic disadvantage.46
Another possibility is that the markedly low levels of indicators of social support that we documented among women veterans—which is consistent with prior VA work (where gender comparisons were not available)22
—contribute to their ill health. While our cross-sectional study could not test this directly, it is well established that low levels of social support are associated with adverse health outcomes.16–20
Even when married, women tend to bear a heavier burden of care giving and may receive less support themselves than do men.47, 48
This is consistent with our finding that being married or living with someone appears to benefit mental health status in men but not women. In contrast, instrumental support (having someone who could take the patient to the doctor when needed) does benefit mental health status in women. Therefore, VA's efforts to outreach to vulnerable populations—e.g., with in-home care, transportation benefits, and satellite primary care centers—may prove of particular value to women.
Gender differences varied across age cohorts. In particular, while health status summary scores were mostly comparable in women and men, an exception was that women over age 65 years had better mental health summary scores than did men. In this group the effect of social support upon mental health status was also less pronounced. Therefore, it is possible that women in this cohort had access to some types of social support (e.g., networks of friends or qualitatively different types of relationships) less available to men. Alternatively, the women in this oldest group (who represent mostly World War II and Korean era veterans) may have acquired some specific patterns of coping which distinguish them from men of their era.
With ongoing growth of women's representation in the armed services, the health care needs of VA's youngest female enrollees (who may receive VA care for the remainder of their lives) also require special scrutiny. Like their older female counterparts, young women tend to be more highly educated than men in VA, yet are less likely than men to be employed or married or to use VA as their exclusive source of care. VA needs to take possible economic hardship into account when planning care for this emerging population, given the established connections between poverty and ill health.49, 50
Clinicians will also need to monitor the degree to which their care is coordinated across health care systems. Women veterans in the youngest age group did not exceed men in dimensions of the Veterans SF-36 (unlike older women). Therefore, the possibility that, as they age, the newest cohort's health care needs will prove to be greater than those of current cohorts of older women veterans deserves exploration.
Our study must be interpreted subject to several considerations. While the response rate was high for a large national survey, the characteristics of VA patients who responded to the survey could differ from those of veterans who did not. It is also important to recognize that women veterans who use VA services may be different from women veterans who do not use VA; our findings cannot necessarily be extrapolated to the latter population. Finally, because of the cross-sectional nature of our data, causal conclusions about the association between social support and health status cannot be drawn.
Despite these limitations, there are major strengths of our study. We sampled a large proportion of the women veterans who use VA services, maximizing our ability to represent the health status of this special population. To do so, we used a well-validated measure of health status known to correlate with objective outcomes such as severity of medical conditions and mortality.32, 51
We also had the opportunity to assess indicators of social support, a strong but often neglected predictor of health.
Our study has important implications for policy makers, researchers, and health care providers. Strong age cohort effects are seen, suggesting that approaches to providing care for older women veterans may not apply to recent military discharges. Caring for the large subgroup of women with low levels of social support will require interventions sensitive to social context; to compensate for gender role differences in our society, the nature of such interventions may need to be different in women than in men. It is well known that male VHA patients have worse health status than men in the general population; our work demonstrates that female VHA patients are not substantially better off, suggesting they will require comparable intensity of services.